Medical History Form-Columbus Community Hospital
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2Medical History Form
Patient#: __________________________
Today’s Date: ________________________
Name: ______________________________________________________________________________
First
MI
Last
Height: _________
Weight: ________ I am: Right hand dominant Left hand dominant
Family Physician: _______________________ Pharmacy: ___________________________________
Reason For Visit: Briefly describe the reason for your visit to our clinic:
Left
Right
______________________________________________________________________________________
Medical History:
Are you affected by any of the following? (Check all that apply)
NO MEDICAL PROBLEMS
Abnormal heart rhythm
Diabetes
Emphysema
Liver disease
Alcoholism
Endometriosis
Low back pain
Kidney stone
Anemia
Gout
Lung Disease
Kidney failure
Anorexia/Bulimia
Heart Attack
Osteoarthritis
Thyroid disease
Anxiety
Heart Failure
Osteoporosis
Tuberculosis
Asthma
Hepatitis
Ovarian cysts
Depression
Bleeding disorder
HIV
Rheumatoid arthritis
Stroke
Blood clots
High Cholesterol
Seizures
Stomach Ulcers (GERD)
Bronchitis
Hypertension
Irritable Bowel
Lupus
Schizophrenia
Mentally challenged
Migraines
Fibromyalgia
Drug Abuse
Neuropathy
Cancer (type_______________)
Other ________________________
Other ___________________________
SURGERIES: NONE
Appendectomy
Bladder surgery
Back /Spine surgery C-Section
Cardiac Bypass surgery Carpal tunnel release
Gall Bladder Removed Hernia repair
Hysterectomy
Tonsillectomy
Previous Fractures
Shoulder arthroscopy Rt. Lt. Knee Scope Rt. Lt.
Rotator Cuff Repair Rt. Lt.
Total Joint Replacement Rt Lt hip knee
shoulder
Foot/ankle surgery
Rt. Lt. ____________
Other __________________________________________________________________
FAMLY HISTORY:
?:
Has anyone in your immediate family ever had any of the following
M=Mother F= Father S=Sister B=Brother GF= Grandfather GM = Grandmother
____Diabetes ____Osteoporosis
____Stroke
____Bleeding Disorder ____Genetic Disorder
____Cancer_______________Type of Cancer ____Heart Attack ____High Blood Pressure
____ Malignant Hyperthermia
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